Dr. Raymond Bertolotti, a giant in the history of bonding, literally coined the term “adhesion dentistry” in 1985. He is perhaps best known for introducing the total-etch technique to North America. I had the opportunity to talk with him about the history of collage and where we are in 2022.
Dr. Joshua Austin: Dr. Bertolotti, you’ve been teaching dentists about bonding for years. If you could press a button and instantly download one piece of bonding knowledge into every dentist’s brain, what would it be?
Dr Raymond Bertolotti: I think it’s important to remember Professor Takao Fusayama (a pioneer of minimally invasive and adhesive dentistry) as much as Greene Vardimin “GV” Black (one of the founders of modern dentistry in the United States) . With total etching and the help of Kuraray chemists, Professor Fusayama taught us to be “tooth doctors, not to destroy teeth”.
JA: That’s a great point. My dad was a dentist in the 60s, 70s and 80s. I think he would think my preparations were rubbish and grossly underprepared if he could see them today. I was trained by Dr. Jim Summitt in San Antonio, and amalgamation was a big part of our education. We learned from the posterior composite, but that was secondary. I know that tens of thousands of dentists have gone through the same training as me. Do you think most dentists today understand the differences between amalgam preparations and composite resin preparations? Do you think there are rules of thumb that are often ignored when preparing?
RB: I doubt most dentists understand the differences between good preparations (retaining tooth structure and reducing stress) for mechanically retained amalgams and bond-retained composites. Even some prominent thought leaders, such as Gordon Christensen, DDS, PhD, persist in distrusting adhesion, as evidenced by their placement of retention characteristics in composite preparations. Since the early 1980s, I have never seen a total debonding of a class II composite that I placed.
GV Black had no adhesives, so mechanical retention was required. However, from a technical point of view, placing sharp line angles at the base of the amalgam could be called stupid. How many of them resulted in fractured teeth, the fracture coming from the acute angle of the line? I see them frequently. Wouldn’t it be much better if the prep was cut with a pear-shaped bur, providing retention as well as rounded line angles (reducing stress)?
JA: I went to dental school when the fourth generation bond was king. Today, it seems that the industry has turned to universal adhesives. What do you think of this change?
RB: This is not a good decision for those who want the best connection possible. This appears to be a marketing effort to simplify bonding for dentists who don’t want to take the time to learn optimal bonding or those who can’t follow instructions. I don’t know of any universal adhesive that can match an optimal bond with the best adhesive for the given application.
JA: This is interesting information. What do you want to tell restorative dentists about choosing a bonding agent that is best for them? Any advice on finding the right bond?
RB: A dentist must decide if a compromise between bond strength and durability for a particular surface is acceptable. If so, the use of a universal bonding agent may be acceptable. If the application is critical, it may be imperative to choose a bonding agent for best performance. It may be that the universal can be used most of the time and the dedicated link used when needed.
JA: I graduated from dental school in 2006. Dr. Jim Summitt taught us that total etching was the only way, but lately we have heard a lot about the dangers of etching dentin with phosphoric acid . Where are you as one of the pioneers of the total etching technique?
RB: After learning total etching from Professor Fusayama in 1981, I tried it with his Clearfil Bond System-F. Gone is the sensitivity to composites without inserts and the need for mechanical retention. I never looked back. I started teaching “Total Burn, Total Seal, Total Success” in 1983 when we started the fifth quarter seminars. I received mainly reports of clinical successes, despite the opposition of many famous academics. The occasional negative reports indicated that attention to detail was necessary for success. When self-etching with Liner Bond 2 was introduced in 1994, it was obvious that there was less technical sensitivity. Predictability has progressed as products and techniques have been perfected. Now, total etching, performed separately or with self-etch products, is the standard of care.
JA: Thank you! This is excellent information. Finally, do you have any advice for dentists who are considering changing glue?
RB: Manufacturers currently seem to be aiming for simpler and faster products. It’s fine as long as we get acceptable results. However, the definition of “acceptable” is debatable. I would choose products based on their track record of success for at least three years, based on independent studies conducted by reliable investigators.
Editor’s note: This article originally appeared in the May 2022 print edition of Dental economy magazine. Dentists in North America can take advantage of a free print subscription. Register here.